Back pain often treated with wrong treatment

Many patients are getting overly aggressive treatments for their back pain, says a large study out today.

Physicians today are increasingly giving patients with back pain narcotic drugs, ordering expensive imaging tests or referring them to other physicians rather than offering them the recommended first line of treatment. That more conservative treatment calls for the use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin, Advil), aspirin and naproxen (Aleve), or acetaminophen (Tylenol) and physical therapy, according to national guidelines from the American College of Physicians.

The guidelines caution against early imaging or other aggressive treatments, except in rare cases, says the study's lead author John Mafi, a chief medical resident at Beth Israel Deaconess Medical Center, Boston.

These guidelines are similar to those from other groups, and the bottom-line message is "less is more," Mafi says. "The majority of cases of patients with new back pain tend to get better with conservative treatment in three months. If they don't get better, physical therapy is an option. Narcotic medications, such as Percocet or Vicodin, have no proven efficacy in improving chronic back pain."

Back pain is one of the most common reasons for going to the doctor; more than 10% of visits to primary-care physicians are for this problem and amounts to about $86 billion in health care spending annually, says senior author Bruce Landon, a professor of health care policy and medicine at Harvard Medical School. That's a conservative estimate because it doesn't account for lost productivity, he says.

Using data from two national surveys, the researchers studied almost 24,000 visits to the doctor for back pain, both acute and chronic, from 1999 to 2010.

Findings published Monday in JAMA Internal Medicine, a Journal of the American Medical Association Network publication:
- The recommendation for using NSAIDs or acetaminophen per visit decreased from almost 37% in 1999 to about 24.5% in 2010.
- Narcotic drug use increased from about 19% in 1999 to about 29% in 2010.
- Physician referrals increased from about 7% in 1999 to 14% in 2010.
- Scans, such as computed tomography (CT) or magnetic resonance images (MRIs), rose from about 7% to about 11% during that same period.
- Physical therapy remained unchanged at about 20%; X-rays remained unchanged at about 17%.

"With health care costs soaring, improvements in the management of back pain represent an area of potential cost savings for the health care system while also improving the quality of care," the study says.

So why are doctors using these types of treatments?

"Patients expect doctors to have some kind of magic cure, and so doctors want to offer them something," Landon says. "Often it's easier to offer them something rather than explaining why more aggressive treatments and testing won't make them better in the long run."

Donald Casey Jr., a clinical professor of medicine in the department of population health at New York University School of Medicine, who wrote the accompanying editorial, says there are a lot of different reasons for the findings, including the fact that there are 183 different guidelines just for treating low back pain. "A well-constructed clinical practice guideline doesn't always give you the exact treatment for every single patient every time. But it should give physicians guidance about which treatments are most likely to work best for most patients."